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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA NV Telephone (209) 466-6781 ` PERMIT EXPIRES 1 YEAR FROM GATE ISSUED N O A (Complete in Triplicate) `rte Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instill the work herein dsactibed.This appication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1882 for well/pimp and the Rubs and Regule6ons of the San Joaquin Local Health District. Job Address `�.��" -- -- — City," Lot Sire PM Owner's ams I _ _ Address D"' "'� Phone Contracto yy�d_'14C_Address ' ` License No. Phone TYPE OF WELL/ UMP: NEW WELL (J WELL REPLACEMENT L1 DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ____ DISPOSAL FLD.__ PROP. UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl Manteca Dia.of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public -i Other G Delta Depth of Grout Seal _ Typed Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seel Installed by Repair Work Done ❑ Type of Pump H.P.- State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth __ Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i.I REPAIR/ADDITION❑ DESTRUCTIO (No septic system permitted H public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial — Other Number of living units: Number of bodrooms_. Character of soil to a depth of 3 feet:___ Water table depth _ SEPTIC TANK O Type/Mfg ___ — Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/site FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth _Sire Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 1 hereby certify that I have prepared this application and that the work will bu dons in accordance with San Joaquin county ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit Is Issued,1 slta8 not employ any person In such manner as to becomn aubinct to workman's compensation laws of Celifomla."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is Issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant cast call for 1 r uir spections. Comp) drawing ever"aide. Signed)L Title: Date: r FOR DEPARTMENT USE ONLY Application Accepted by _�J��'(I,�nn � _ Date — �� Ans. O Pit or Grout Inspection by _.___.___. Date Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 i I Manteca 823.7104 ❑ Tracy 8368386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED K s RECEIVED BY DATE PERMIT-NO. INFO CASH . EH 17-:4 IAEV i n.,i s/l l� Z.Q •- 'f�